Gwendolen T. Buhr

Is Obesity Bad for Older Persons? A Systematic Review of the Pros and Cons of Weight Reduction in Later Life

OBJECTIVES The purpose of this review was to describe the characteristics of late-life obesity, including prevalence, pathophysiology, and influences on morbidity and mortality. A second objective was to systematically review the empiric evidence on the effects of intentional weight loss interventions in older individuals. DESIGN We summarized the characteristics and known impact of late-life obesity and conducted a systematic review of the outcomes of weight loss interventions in obese older subjects. The inclusion criteria for the review were the following: randomized controlled trial; subjects aged 60 years or older; baseline BMI 27 or higher; weight loss versus baseline 3% or more or 2 kg; and trial duration 6 months or longer. RESULTS The search strategy yielded 16 articles on weight loss interventions that were examined in detail. Overall, these interventions led to significant benefits for those with osteoarthritis, coronary heart disease, and type 2 diabetes mellitus (DM-2), while having slightly negative effects on bone mineral density and lean body mass. CONCLUSION Longitudinal trials examining mortality and body weight suggest that maintaining weight is beneficial in older persons who become obese after age 65; in contrast, intervention trials show clinically important benefits of weight reduction with regard to osteoarthritis, physical function, and possibly DM-2 and coronary heart disease. Given these findings, we recommend that decisions about whether or not to institute a weight loss intervention for obese older persons be carefully considered on an individualized basis with special attention to the weight history and the medical conditions of each individual.

Difficult Behaviors in Long-term Care Patients With Dementia

Difficult behaviors are relatively common challenges that can occur throughout the natural progression of dementia, but are particularly common in the mid to late stages of disease. These behaviors can be challenging to manage in nursing and assisted care facilities, and can cause distress to the caregivers and to the patients themselves. Our ability to manage these symptoms can have a profound effect on the patients quality of life. This article reviews the appropriate assessment of behavioral and psychological symptoms of dementia (BPSD) and the literature supporting various nonpharmacologic and pharmacologic treatments. Nonpharmacologic approaches should be the initial focus for treatment of most BPSD, but should these prove inadequate, a variety of medications are available with varying degrees of clinical research to support their use in ameliorating BPSD.

Nutritional Supplements for Older Adults: Review and Recommendations—Part I

The majority of older adults take nutritional supplements (NS) to prevent deficiencies and/or because they are interested in the potential health promoting effects of these nutrients. This review explores the evidence of benefit for supplements of multivitamin/minerals (MVM), antioxidant nutrients, and vitamin D/calcium. Major conclusions include the following: While recommendations that older adults take a daily MVM are common, there is limited scientific support for the health-related efficacy of these supplements. In contrast, a number of antioxidant nutrients have been extensively studied. The evidence does not support a recommendation for vitamins A, C, E, or antioxidant combinations in the prevention of CVD or cancer. Based on encouraging preliminary findings, more study is recommended on the benefit of antioxidant supplements for age-related macular degeneration and of selenium for cancer prevention. In contrast to the state of the art for antioxidant supplements, there is strong and compelling support for the health benefits of supplements of Vitamin D and calcium when intake/status of these nutrients is not optimal. Thus, specific recommendations for these supplements in older adults are warranted.

Implementing Culture Change in Nursing Homes: An Adaptive Leadership Framework

PURPOSE OF THE STUDY To describe key adaptive challenges and leadership behaviors to implement culture change for person-directed care. DESIGN AND METHODS The study design was a qualitative, observational study of nursing home staff perceptions of the implementation of culture change in each of 3 nursing homes. We conducted 7 focus groups of licensed and unlicensed nursing staff, medical care providers, and administrators. Questions explored perceptions of facilitators and barriers to culture change. Using a template organizing style of analysis with immersion/crystallization, themes of barriers and facilitators were coded for adaptive challenges and leadership. RESULTS Six key themes emerged, including relationships, standards and expectations, motivation and vision, workload, respect of personhood, and physical environment. Within each theme, participants identified barriers that were adaptive challenges and facilitators that were examples of adaptive leadership. Commonly identified challenges were how to provide person-directed care in the context of extant rules or policies or how to develop staff motivated to provide person-directed care. IMPLICATIONS Implementing culture change requires the recognition of adaptive challenges for which there are no technical solutions, but which require reframing of norms and expectations, and the development of novel and flexible solutions. Managers and administrators seeking to implement person-directed care will need to consider the role of adaptive leadership to address these adaptive challenges.

Prioritizing Culture Change in Nursing Homes: Perspectives of Residents, Staff, and Family Members

To explore the perspectives and priorities of nursing home residents, family members, and frontline nursing staff concerning a broad range of items representing common targets of culture change initiatives.

Urinary Tract Infections in Long-Term Care Residents

Urinary tract infection (UTI) is common in long-term care (LTC) residents; however, most infections are asymptomatic and do not require treatment. Differentiating asymptomatic from symptomatic UTI is challenging, because LTC residents typically have chronic genitourinary complaints, multiple comorbid illnesses, and communication barriers. Although consensus guidelines have been proposed to improve the accuracy of identifying symptomatic UTIs and minimize treatment of asymptomatic UTIs, diagnostic accuracy is not yet optimized. Strategies for prevention of UTI are unsatisfactory and require further study; nevertheless, there is some evidence for the efficacy of cranberry products and vaginal estrogen to prevent recurrent UTI in women.

Body Mass Trajectory, Energy Balance, and Weight Loss as Determinants of Health and Mortality in Older Adults

The relationship between body mass (usually measured as BMI in kg/m2) and healthy longevity is a major focus of study in the nutrition and aging field. Over-nutrition now rivals frailty as the major nutritional concern; the number of older adults who are obese has increased dramatically in the past 3 decades. While obesity exacerbates a host of life-threatening, age-related chronic diseases, a somewhat paradoxical finding is that being somewhat overweight in old age appears to be a benefit with regard to longevity. In our recently completed systematic review of randomized controlled weight reduction trials, we found that weight loss interventions in overweight/obese older subjects led to significant benefits for those with osteoarthritis, coronary heart disease, and type 2 diabetes mellitus, while having slightly negative effects on bone mineral density and lean body mass. In contrast to this finding, the preponderance of epidemiological evidence indicates that higher BMIs are associated with increased survival after age 65 years. Because of this contradictory state of the science, there is a critical need for further study of the relationship of weight and weight loss/gain to health in the later years of life.

Mentoring: A Key Strategy to Prepare the Next Generation of Physicians to Care for an Aging America

Mentoring is an important instructional strategy that should be maximally used to develop the next generation of physicians who will care for a growing population of frail older adults. Mentoring can fulfill three specific purposes: (1) help learners choose an area of specialty, (2) help fellows and new faculty navigate advancement in the academic environment, and (3) help new physicians enter a local medical community and develop a high‐quality, professionally rewarding, financially viable practice that meets the needs of older adults. The components and process of mentoring are reviewed. Current and potential mechanisms to promote mentoring for the specific purpose of increasing the quality and quantity of physicians available to care for the older adult population are discussed.

Ensuring Vitamin D Supplementation in Nursing Home Patients—A Quality Improvement Project

Randomized controlled trials have shown that adequate vitamin D supplementation in nursing home (NH) residents reduces the rates of falls and fractures. In our NH, review of medication administration records of all patients (n = 101) revealed that only 34.6% of the patients were currently prescribed adequate doses of vitamin D, revealing a need for intervention. We designed a Quality Improvement (QI) project with the objective of improving the vitamin D prescription rate in our NH. We used the Plan-Do-Study-Act (PDSA) approach to implement this QI project. Patients not currently prescribed an adequate dose of vitamin D were identified and started on a daily dose of 800 IU of vitamin D. Additionally, patients who were experiencing falls while on an adequate dose of vitamin D for 3 months were examined for the possibility of vitamin D deficiency and were started on 50,000 IU of vitamin D per week for 12 weeks if they were found to be vitamin D-deficient based on blood levels of 25-hydroxy-vitamin D below 30 ng/mL. We found that with several PDSA cycles over a period of 5 months, the prescription rate for vitamin D was increased to 86%, surpassing our initial goal of 80%. In conclusion, we found that a multidisciplinary QI program utilizing multiple PDSA cycles was effective in reaching target prescription rates for vitamin D supplementation in a population of NH patients.

An Advanced Course in Long Term Care for Geriatric Medicine Fellows

Long term care deserves focused attention within a geriatric medicine fellowship curriculum to ensure that graduates are prepared not only for clinical care but also for the leadership, administrative, educational, quality improvement, and health policy aspects of their future roles. This report describes the curriculum development and program evaluation of an advanced course in long term care for geriatric medicine fellows and other graduate/post-graduate health professionals at Duke University. Course evaluation had 4 goals: (1) to determine how well the learning objectives were met; (2) to evaluate individual components of the course to improve subsequent offerings; (3) to determine whether additional topics needed to be added; and (4) to evaluate the effectiveness of the discussion forum component of the course. Learner self-efficacy improved within all competency areas but especially those of practice-based learning and system-based practice. Evaluation results led to curriculum revision that has maintained course relevance and sustained it within the larger geriatrics fellowship curriculum. Components of this course can be easily adapted to other curricular settings for fellows and residents.